What are the risk factors for hypertension?

Risk Factors for Hypertension

Hypertension is driven by a combination of modifiable lifestyle factors—particularly obesity, physical inactivity, high salt intake, smoking, and alcohol consumption—along with non-modifiable factors including advanced age, male sex, and family history. 1

Modifiable Risk Factors

Metabolic and Lifestyle Factors

• Overweight and obesity affect 40-49.5% of hypertensive patients and represent the single most prevalent modifiable risk factor, with 35.7% of obese individuals developing hypertension 1, 2
• Physical inactivity and low fitness levels contribute significantly to hypertension risk through multiple pathophysiological mechanisms including sympathetic nervous system activation 1, 3
• Unhealthy diet, particularly high salt intake and inadequate fruit/vegetable consumption (fewer than 5 servings daily), directly elevates blood pressure through volume expansion and endothelial dysfunction 1, 4, 3
• Diabetes mellitus is present in 15-20% of hypertensive patients, with 71% of US adults with diagnosed diabetes having concurrent hypertension 1, 3

Substance Use

• Current cigarette smoking and secondhand smoke exposure cause endothelial dysfunction, promote atherosclerosis, and increase platelet aggregation 1, 5, 6, 4
• Excess alcohol consumption affects 43.4% of some populations and activates the renin-angiotensin-aldosterone system 1, 6, 4, 7

Cardiovascular Comorbidities

• Dyslipidemia/hypercholesterolemia (elevated LDL-C and triglycerides) coexists in 63.2% of hypertensive adults, sharing common pathophysiological mechanisms including endothelial dysfunction 1, 5, 8
• Metabolic syndrome is present in 40% of hypertensive patients, representing a cluster of obesity, insulin resistance, dyslipidemia, and elevated blood pressure 1
• Hyperuricemia affects 25% of hypertensive patients and should be considered as a contributing factor 1

Non-Modifiable Risk Factors

Demographic Factors

• Advanced age (>65 years) is the strongest independent risk factor, with cardiovascular risk increasing substantially after this threshold 1, 5
• Male sex confers higher cardiovascular risk compared to pre-menopausal women of the same age 1, 5
• Family history of hypertension or premature cardiovascular disease significantly increases risk, with sibling history carrying stronger predictive value than parental history 1, 5

Medical Conditions

• Chronic kidney disease (CKD) with eGFR <60 mL/min/1.73m² is present in 15.8% of hypertensive adults, with 86% of CKD patients having hypertension 1, 3
• Obstructive sleep apnea represents a difficult-to-modify risk factor that contributes to resistant hypertension 1

Additional Risk Modifiers

Psychosocial and Socioeconomic Factors

• Psychosocial stress and psychiatric disorders increase cardiovascular risk through neuroendocrine mechanisms, though current interventions may not reduce this risk 1, 5
• Low socioeconomic/educational status represents a difficult-to-modify risk factor associated with higher hypertension prevalence 1
• Early-onset menopause in women increases cardiovascular risk 1

Emerging Factors

• Elevated heart rate (>80 beats/min) serves as an independent risk marker 1
• Chronic inflammatory diseases (COPD, rheumatoid arthritis, systemic lupus erythematosus, psoriasis) increase cardiovascular risk and warrant effective blood pressure control 1, 5

Clinical Implications

The presence of multiple risk factors creates multiplicative rather than additive cardiovascular risk. Among US adults with hypertension, 41.7% have a 10-year coronary heart disease risk exceeding 20%, while only 18.4% have risk below 10% 1, 8, 2. More than 50% of hypertensive patients have at least one additional cardiovascular risk factor, and the presence of ≥3 risk factors substantially increases lifetime risk of cardiovascular death, myocardial infarction, and stroke 1.

Common Pitfalls to Avoid

• Do not assess hypertension in isolation—always evaluate for coexisting diabetes, dyslipidemia, obesity, and kidney disease, as these frequently cluster together and require simultaneous management 1
• Do not overlook family history, particularly sibling history of premature cardiovascular disease, which carries stronger predictive value than parental history alone 5
• Do not dismiss psychosocial stressors in patients with resistant hypertension, as chronic stress contributes to poor blood pressure control through sympathetic nervous system activation 1